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RA981J25  1912       The  organization  of 

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The  organization  of  an  American  univer- 
sity medical  clinic 


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[Reprinted  from  The  Columbia  University  Quarterly,  Vol.  XIV.,  No.  3.  June,  1912.I 


THE  ORGANIZATION  OF  AN  AMERICAN  UNIVERSITY 
MEDICAL  CLINIC* 

IN  any  institution,  organization  is  the  body — dead,  unless  anima- 
ted by  and  expressing  aims  and  ideals ;  and,  as  in  the  scriptural 
antithesis  between  faith  and  works,  ideals  can  come  to  fruition  only 
as  they  are  embodied  in  and  realized  through  organization. 

In  America  today  no  organization  exists  which  expresses  ade- 
quately the  modern  ideal  of  a  medical  clinic.  The  ideal  is  now 
widespread.  The  task  of  the  present  generation  is  to  create  an 
organization  which  shall  best  express,  down  to  the  minutest  detail, 
the  highest  aims.  Modern  science  has  taught  us  more  and  more  to 
look  upon  creation,  however,  not  as  the  sudden  making  of  some- 
thing out  of  nothing,  but  as  the  gradual  evolution  of  higher  and 
more  complex  out  of  lower  and  simpler  forms.  We  who  are  dis- 
satisfied with  existing  conditions  here  do  well  to  heed  this  teaching. 
Human  organizations  of  whatever  kind  are  intelligible  only  in  the 
light  of  historic  development.  Any  future  forms  must  have  their 
roots  in  the  institutions  of  yesterday  and  today,  and  of  our  own 
country.  We  may  study  the  examples  of  other  lands  and  learn 
from  their  experiences  much  to  admire,  much  to  avoid ;  but  nothing 
to  be  copied  blindly  without  adaptation. 

Perhaps  I  should  define  at  the  outset  just  what  I  mean  by  a 
medical  clinic.  I  conceive  that  a  medical  clinic  is  a  complete,  inde- 
pendent hospital  department  equipped  for  and  engaged  in  teaching 
internal  medicine.  From  its  very  nature,  then,  the  medical  clinic 
serves  two  masters — the  hospital  and  the  teaching  institution;  it 
has  entrusted  to  it  dual  interests — the  bodies  of  the  patients  and  the 
minds  of  the  students.  Can  it  serve  both  masters  and  safeguard 
both  trusts  equally  and  faithfully?  That,  I  believe,  is  for  the  Amer- 
ican university  medical  clinic  of  the  future  to  prove.  We  should  be 
satisfied  with  nothing  else.  That  the  task  is  a  more  difficult  one 
than  confronts  any  other  university  department  seems  clear.  That 
it  has  ever  been  fully  accomplished,  I  shall  not  dare  claim. 

*  Address  delivered  before  the  Aesculapian  Club  of  Boston,  January  20,  igi2. 
260 


261  Columbia  University  Quarterly  [June 

With  perhaps  a  single  exception,  such  medical  climes  as  exist  in 
America  today  are  organized  fraiikly  for  the  benefit  of  the  patient, 
as  conceived  by  a  lay  board  of  hospital  managers.  Nor  should  we 
blame  these  men.  Any  change  which  medical  teachers  propose 
must  abate  not  one  jot  or  tittle  of  this  solicitude  for  the  sick  man, 
the  first  care  alike  of  hospital  physician  and  hospital  manager.  I 
am  convinced  that  nowhere  in  the  world  does  a  hospital  patient 
receive  such  good  care  as  in  our  best  American  hospitals.  This  is 
due  in  part  to  the  excellence  of  the  nursing  organization,  and  in  part 
to  the  high  level  of  administrative  ability  and  the  rather  ample  re- 
sources of  our  finest  hospitals;  and  last  but  not  least  to  the  hearty 
cooperation  between  medical,  nursing,  and  administrative  staffs. 
At  bottom,  however,  it  is  dependent  upon  medical  self-sacrifice 
for  its  existence,  and  often  breaks  down  when  this  is  too  severely 
taxed.  For  this  very  reason,  our  traditional  American  hospital  can- 
not be  considered  as  having  a  permanent  form  of  organization, 
because  no  institution  can  depend  indefinitely  and  at  all  times  upon 
voluntary  service — not  even  the  time-honored  House  of  Commons, 
as  we  have  but  recently  seen.  At  this  point  of  least  resistance  the 
typical  American  hospital  service  is  already  breaking  down.  In 
one  way  or  another,  permanent,  trained,  technical  assistants  in 
laboratories,  in  x-ray  departments,  in  departments  of  physical  thera- 
peutics, are  proving  necessary  for  the  modern  diagnosis  and  treat- 
ment of  the  sick  and  are  rapidly  being  introduced.  In  many  hos- 
pitals semi-permanent,  paid,  resident  medical  officers  are  being 
placed  over  the  unpaid  interne  staff.  Who  shall  direct  and  coor- 
dinate the  various  activities  of  these  men,  to  the  end  that  the  patient 
may  receive  the  full  benefit?  Surely  not  a  series  of  busy  practi- 
tioners themselves  untrained  in  such  methods  and  changing  every 
few  months.  Under  such  a  system,  our  hospitals  would  soon  be- 
come bureaucracies,  governed  by  subordinates ;  perhaps  some  already 
are.  Even  under  the  traditional  system,  house  staffs  were  fre- 
quently more  important  than  their  superiors  in  determining  the 
character  and  scope  of  the  hospital's  work.  Here  is  the  American 
hospital's  need  for  the  American  university,  and  the  opportunity 
for  the  American  university  medical  clinic.  Of  the  university's 
need  for  the  hospital  so  much  has  already  been  well  stated  that  repe- 
tition would  be  but  a  waste  of  time. 


I9I2J  Organization   of  Medical   Clinic  262 

In  evolving  from  the  best  existing  American  hospitals  the  Amer- 
ican clinic  of  the  future,  what  may  be  learned  from  the  experience 
of  Great  Britain,  of  Germany,  of  France?  First,  it  is  clear  that 
however  different  in  detail  the  forms  of  organization  in  these  coun- 
tries, all  have  this  in  common,  that  a  hospital  unit  is  always  under 
the  direction  of  a  single  physician.  The  rotating  visiting  service 
in  the  United  States  was  clearly  a  temporary  expedient,  to  meet  the 
conditions  of  new  institutions  in  a  new  country  devoted  to  demo- 
cratic ideals.  Resources  were  not  available  and  the  physicians 
could  not  be  paid,  and  therefore  could  not  be  asked  to  give  their 
services  except  for  a  limited  portion  of  the  3'ear.  It  was  desirable, 
too,  that,  in  small  communities,  the  hospitals  should  contribute  as 
much  as  possible  to  the  education  of  the  entire  medical  profession, 
as  general  practitioners ;  and  in  small  communities  today  the  system 
seems  well-suited  to  supply  the  community's  most  urgent  need,  the 
raising  of  the  general  level  of  efficiency  among  its  physicians.  In 
cities  large  enough  to  become  educational  centers,  the  end  of  the 
system  is  already  in  sight 

The  organization  of  the  English  and  Scottish  teaching  hospitals 
is  based  primarily  upon  their  fundamental  method  of  clinical  in- 
struction— the  clerkship  under  visiting  physicians  of  ripe  expe- 
rience. That  method  is  the  great  contribution  of  Great  Britain  to 
medical  education.  Last  summer  in  Munich  I  was  an  auditor  at 
Professor  Friedrich  Miiller's  first  clinic  after  his  return  from  Eng- 
land, where  he  had  gone  to  testify  before  the  British  Royal  Com- 
mission on  Medical  Education.  He  told  his  students  that  two 
things  he  had  seen  had  greatly  impressed  him:  First,  an  examina- 
tion which  he  said  was  conducted  with  more  rigor  and  thoroughness 
than  any  he  had  known;  secondly,  the  work  of  the  clinical  clerks. 
The  practical  instruction  of  the  British  medical  student  as  a  clerk, 
he  told  his  hearers,  was  far  superior  to  any  similar  instruction  in 
Germany,  their  Praktikantenjahr  at  the  end  of  the  medical  course 
being  but  a  makeshift  for  continuous  personal  contact  between  stu- 
dent and  patient.  Germany's  difficulty,  he  said,  lay  in  the  great 
number  of  medical  students,  which  made  any  introduction  of  the 
clerkship  system  under  present  conditions  impossible.  We,  here 
in  America,  thanks  principally  to  the  lead  of  Dr.  Osier,  have  come 


263  Coliiinbia    University   Quarterly  [June 

to  appreciate  and  adopt  this  system.  At  Columbia  it  has  been  in 
complete  operation  now  for  three  years  with  most  conspicuous  suc- 
cess— from  the  standpoint  alike  of  the  students,  the  teachers,  and 
the  hospitals. 

Since  in  Great  Britain  the  medical  schools  are  for  the  most  part 
intimately  associated  with  a  teaching  hospital  and  only  remotely 
with  a  university,  the  clinical  teachers  are  not  men  of  academic  type, 
but  look  forward  to  a  consulting  practice  as  the  real  reward  of  their 
hospital  activities.  Being  unpaid,  they  therefore  prefer  to  under- 
take small  services  only,  and  the  hospital  consists  of  a  number  of 
such  small  independent  units  complete  in  themselves  for  the  educa- 
tion of  clinical  clerks,  but  inadequate  for  other  types  of  medical 
instruction.  Since  each  physician  has  but  forty  or  fifty  beds  at 
most  under  his  care,  his  supervision  of  the  treatment  of  patients  is 
excellent ;  but  his  subordinates  are  inadequate  for  anything  beyond 
bare  routine.  He  has,  as  a  rule,  but  one  resident  house  officer, 
assisted  by  two  grades  of  clinical  clerks  and  well-trained  nurses. 

The  German  clinics,  on  the  other  hand,  may  be  considered  the 
expression  of  the  German  university  system  with  its  survival  of  the 
cathedra  of  the  medieval  schoolmen  and  its  akademische  Lern-  und 
Lehrfreiheit  for  students  and  professors  alike.  The  lecture  or  the 
large  amphitheater  clinic  are  the  backbone  of  the  instruction,  and 
for  the  most  part  the  student  must  arrange  for  his  practical  courses 
from  the  Privatdozenten.  The  clinics  are  large,  the  Leipzig  med- 
ical clinic,  for  instance,  having  about  eight  hundred  beds.  The 
clinical  lectures  are  admirable,  and  the  whole  organization  is  per- 
meated with  a  spirit  of  the  most  active  scientific  investigation,  but 
it  is  fundamentally  autocratic.  The  care  of  the  individual  patient 
is  largely  the  concern  of  the  individual,  rather  than  the  object  of 
the  organization.  The  professor  of  medicine  is  the  director  of  the 
clinic  and  is  theoretically  responsible  for  the  supervision  of  the  treat- 
ment of  all  patients.  He  has,  as  a  rule,  one  assistant  for  each  forty 
or  fifty  beds,  the  elder  of  these  assistants  being  Privatdozenten  in 
the  university.  Most  of  them  arc  residents  of  the  hospital.  They 
have  immediate  charge  of  the  care  of  their  patients  and  the  routine 
duties  of  the  service,  are  actively  engaged  in  investigation,  give 
special  courses  in  diagnosis,  and  so  forth.     They  serve  for  an  un- 


1912]  Organisation   of  Medical   Clinic  264 

limited  period,  often  for  many  years,  on  small  salaries,  and  pursue 
from  the  outset  an  academic  career  whose  goal  is  a  professorship. 
The  best  of  them,  selected  through  a  stern  competition  in  the  field 
of  scientific  investigation,  become  the  future  directors  of  the  Ger- 
man clinics,  the  first  step  in  promotion  being  the  habilitation  as  a 
professor,  then  the  call  to  the  directorship  of  one  of  the  smaller 
university  clinics.  Finally,  those  who  prove,  masters  reach  the 
directorships  of  the  great  medical  clinics  of  the  empire.  In  the 
care  of  the  patients  they  are  assisted  by  the  rather  uncertain  supply 
of  students  taking  the  Praktikantenjahr  and  by  volunteers  pursuing 
research  in  the  hospital.  Judged  again  by  American  standards  of 
care,  the  German  system  is  weak  at  this  point,  Avhile  strong  on  its 
educational  and  scientific  sides.  The  instruction  of  the  individual 
student  is  similarly  dependent  upon  the  temperament  of  the  teacher. 
No  such  system  of  carefully  graded  instruction,  with  well-planned 
practical  courses,  which  must  be  taken  in  definite  sequence,  as  we 
have  it  in  America,  would  be  tolerated  in  Germany ;  for  the  German 
university  places  the  advancement  of  knowledge  and  the  freedom  of 
the  professor  first.  The  medical  clinics  are  elaborate  independent 
institutes,  as  a  rule  wonderfully  equipped  for  research,  as  well  as 
for  the  most  perfect  demonstrative  teaching;  but  their  very  com- 
pleteness and  independence  isolates  them  from  the  other  scientific 
departments  of  the  university.  Lack  of  cooperation,  even  of  con- 
tact, between  the  clinical  institutes  and  the  pathological,  the  physio- 
logical, the  hygienic,  and  the  chemical  institutes  is  striking. 

In  France  the  medical  student  pursues  two  independent  and 
parallel  disciplines  from  the  day  of  his  entry  on  his  medical  career — 
one  of  theoretical  and  scientific  instruction  in  the  lecture  rooms  and 
laboratories  of  the  universities,  the  other  as  externe,  and  finally,  for 
the  chosen  few,  as  interne  in  the  hospitals.  The  hospitals  are  thus 
Avidely  separated  from  the  scientific  departments  and  the  heads  of 
the  clinics  give  practical  instruction  in  their  hospitals,  theoretical 
instruction  in  the  usually  distant  university  lecture  room.  Their 
hospital  services  are  of  moderate  size,  usually  about  one  hundred 
beds,  the  newer  ones  fairly  well  equipped  for  research.  The  in- 
struction carried  on  in  them  consists  of  amphitheater  clinics  and 
more  or  less  formal  lectures  delivered  to  small  sections  at  the  bed- 


265  Columbia    University   Quarterly  [June 

side.  The  academic  career  in  France  leads  of  necessity  to  a  large 
practice  and  promotion  in  it  is  at  every  point  obtained  by  the  passing 
of  examinations  conducted  by  the  central  authority,  a  system  which 
greatly  hinders  freedom  of  choice  of  the  teachers.  The  care  of  the 
patients  is  directed  by  the  head  of  the  clinic  on  his  daily  rounds, 
sometimes  with  an  assistant  who  visits  with  him;  but  the  real  care 
is  in  the  hands  of  the  internes,  about  one  for  each  fifty  beds,  also 
chosen  by  examination,  serving  for  a  fixed  period  of  time  and 
assisted  by  the  externe  medical  students  who  are  at  the  hospital  but 
part  of  the  day.  Judged  by  the  standards  of  our  American  hos- 
pitals, the  number  of  physicians  is  inadequate  for  the  best  care  of 
the  patients. 

The  problem  before  the  American  hospital  aspiring  to  become 
a  teaching  clinic  is  that  of  combining  with  what  is  best  in  its  present 
organization — a  high  standard  of  care  and  consideration  for  its 
patients — such  a  well  thought-out  plan  of  education  and  such  oppor- 
tunities for  research  as  shall  embody  all  that  has  been  gained  by  the 
experience  of  European  hospitals  and  clinics.  The  determining 
considerations,  therefore,  fall  into  two  categories — those  which  con- 
cern especially  the  work  of  the  hospital,  the  care  of  the  sick;  and 
those  which  concern  especially  the  university,  the  diffusion  and 
advancement  of  knowledge.  It  will  conduce  to  clarity  of  thought 
if  w€  examine  these  two  sets  of  considerations  separately. 

(i)  The  care  of  patients.  From  the  standpoint  of  patients,  the 
most  important  members  of  a  hospital  staff  are  its  resident  physi- 
cians. That  system  which  attracts  to  the  service  of  the  institution 
the  best  educated  of  the  younger  men,  and  which  retains  them  for 
the  longest  period  of  time,  will  ensure  the  highest  standard  of 
medical  care.  This  seems  certain  to  be  a  system  which  will  provide 
not  alone  for  the  education  of  the  house  staff  as  general  practi- 
tioners, but  will  also  supply  the  stimulus  to,  and  the  opportunity  for, 
scientific  investigation  on  their  part.  Present  house  staffs  serve  the 
hospital  with  singular  devotion,  but  they  leave  just  when  their  ser- 
vices are  becoming  really  efficient.  They  are  overloaded  with  rou- 
tine Vv'ork.  They  have  no  personal  stake  in  any  research  going  on 
in  the  wards.  Therefore,  laboratory  work  and  careful  note  taking, 
upon  which  the  success  of  research  depends,  are  a  drudgery  to  be 


191 2]  Organisation   of   Medical   Clinic  266 

endured  only  for  the  sake  of  the  subsequent  enjoyment  of  the  final 
six  months  as  house  physician.  Yet,  in  any  modern  hospital,  the 
laboratory  work  and  the  note  taking  are  to  the  medical  service  what 
aseptic  technique  and  operating  room  organization  are  to  the  sur- 
gical Thoroughness  in  these  directions  is  the  index  of  the  care 
which  the  patients  receive.  Resident  physicians  serving  for  an  in- 
definite term,  and  making  their  professional  reputations  by  the  work 
they  do  in  the  hospital,  can  alone  give  patients  the  best  that  medical 
science  offers  today. 

These  men  must  have  subordinates,  and  to  maintain  the  Amer- 
ican standard  of  care,  more  subordinates  than  in  foreign  hospitals. 
Internes  of  the  grade  of  the  present  junior  members  of  hospital 
staffs  should  be  provided  for  these  positions,  and  their  course  should 
be  planned  with  reference  to  training  for  general  practice.  From 
the  best  of  these  the  resident  physicians  should  be  chosen. 

On  the  other  hand,  the  visiting  physician  in  one  way  or  another 
has  been  an  essential  feature  of  all  American  hospitals.  He  is  only 
dispensed  with  in  a  few  German  hospitals  where  the  director  lives 
within  the  hospital  and  is  charged  with  administrative  duties  which 
in  this  country  are  better  handled  by  the  hospital  superintendent. 
The  visiting  physician  constitutes  an  important  link  between  the 
hospital  and  the  medical  profession  of  the  communit3^  Men  pur- 
suing a  largely  academic  career  in  medicine  and  much  occupied  with 
teaching  and  the  investigation  of  special  problems,  may  lose  some- 
what of  the  practical  and  the  personal  point  of  view.  Visiting 
physicians  in  charge  of  the  general  wards  will  ensure  mature  judg- 
ment for  the  patients  and  the  best  practical  training  for  the  house 
staff.  Their  relation  to  the  teaching  activities  of  the  clinic  will  be 
discussed  later. 

The  out-patient  service  is  an  indispensable  part  of  a  complete 
hospital  unit,  and  is  equally  important  for  the  care  of  patients  and 
the  instruction  of  students.  Its  organization  should  be  part  of  the 
clinic  organization.  The  English  system,  by  which  the  assistant 
visiting  physician  has  charge  of  the  out-patient  service,  makes  the 
English  dispensaries  far  superior  to  the  American,  which  are,  as  a 
rule,  left  to  recent  graduates  who  have  no  contact  with  the  in- 
patient service.     The  adequate  care  of  patients  having  chronic  dis- 


267  Columbia    University  Quarterly  [June 

eases  requires  continuous  management,  extending  over  long  periods 
of  time — in  the  hospital  ward  during  exacerbations  of  the  disease, 
in  the  out-patient  department  during  periods  of  quiescence.  The 
head  of  the  out-patient  department  must  clearly  be  in  touch  with 
the  ward  service  and  in  complete  control  of  his  subordinates. 

Dr.  Richard  Cabot  has  shown  how  intertwined  are  the  medical 
and  social  problems  of  an  out-patient  department.  No  American 
hospital  is  now  complete  without  a  social  service  department  work- 
ing in  close  cooperation  with  the  medical  clinic.  Such  a  depart- 
ment, in  addition  to  its  usual  functions,  should  make  special  pro- 
vision for  the  following  up  of  discharged  patients.  This  system 
will  eventually  yield  statistics  with  reference  to  the  remote  results 
of  treatment,  and  it  will  ensure  perseverance  in  treatment  after  the 
patient  has  been  discharged.  One  may  also  expect  that  this  evi- 
dence of  the  hospital's  interest  in  them  will  create  in  those  patients 
who  have  passed  through  its  wards  a  feeling  of  personal  loyalty  to 
the  hospital. 

(2)  The  extension  of  knowledge.  The  extension  of  knowl- 
edge has  two  aspects  equally  the  concern  of  the  university — the 
handing  down  of  existing  knowledge,  teaching;  the  acquisition  of 
new  knowledge,  research.  These  are  not  independent  of  each 
other,  for,  in  a  university,  research  is  the  most  important  means 
for  the  education  of  the  teachers  themselves.  The  child  in  his 
study  of  arithmetic  must  apply  the  rules  he  learns  to  the  solution 
of  simple  problems  before  he  becomes  master  of  this  earliest  mathe- 
matical science.  The  medical  student  must  put  into  practice  the 
methods  of  examination  which  he  has  acquired  in  the  diagnosis  of 
actual  cases  of  disease.  The  advanced  student  of  medicine,  in 
which  category  all  teachers  belong,  must  constantly  exercise  him- 
self in  the  investigation  of  the  unsolved  problems  of  medicine  as 
the  most  important  means  of  further  enlarging  his  mental  horizon. 

Medical  teaching  must  be  of  two  types,  extensive  and  intensive. 
By  extensive  teaching  I  mean  the  apphcation  of  the  broad  under- 
lying principles  of  pathological  anatomy,  of  physiology,  bacteriol- 
ogy, and  chemistry  to  the  study  of  disease  in  man;  and  the  familiar- 
izing of  the  student  with  the  varied  manifestations  of  disease  on  as 
large  a  scale  as  possible.     Such  extensive  teaching  must  be  done 


igia]  Organization   of  Medical   Clinic  268 

through  lectures  and  through  large  demonstrative  amphitheater 
clinics.  This  is  clearly  the  task  of  the  head  of  the  teaching  depart- 
ment. It  is  possible  only  where  large  and  varied  clinical  material 
is  at  the  command  of  this  head,  so  that  at  all  times  theoretical  dis- 
cussion may  be  based  upon  clinical  fact  demonstrated  to  the  student. 
The  larger  the  service  under  the  control  of  a  single  professor,  the 
more  perfectly  can  this  important  part  of  the  student's  education 
be  accomplished.  This  is  the  chief  advantage  of  the  German 
organization.  In  addition  to  such  clinical  lectures,  recitations  from 
a  text-book  covering  the  field  of  medicine  systematically  seem  indis- 
pensable in  our  American  schools. 

Intensive  teaching  is  the  thorough  training  of  the  student  in  the 
technique  of  all  the  methods  of  diagnosis  and  of  the  various  thera- 
peutic procedures,  and  in  his  gradual  education  in  the  application 
of  them  to  the  diagnosis  and  treatment  of  disease  in  the  individual 
patient.  This  requires  intimate  contact  between  student  and  patient 
toward  the  end  of  the  medical  course,  with  opportunity  for  the 
closest  first-hand  study  of  a  small  number  of  patients  continuously 
for  a  moderate  period.  For  this,  no  system  approaches  in  efficiency 
the  English  clinical  clerkship,  which  has  now  for  three  years  been 
so  important  a  part  of  the  fourth  year  work  of  the  Columbia  stu- 
dents of  medicine,  following  earlier  years  of  thorough  drill  in  the 
methods  of  physical  and  laboratory  diagnosis.  Such  clinical  clerks 
can  perhaps  best  be  taught  by  men  of  the  type  of  our  present  visit- 
ing physicians,  controlling  units  of  service,  with  adequate  labora- 
tories and  teaching  rooms  adjacent  to  their  wards. 

Another,  and  at  the  present  time  largely  neglected  part  of  the 
student's  education,  is  his  introduction  to  the  literature  of  medicine 
and  his  training  in  its  wise  and  profitable  use.  A  well-stocked 
library  with  full  files  of  all  important  scientific  and  clinical  journals, 
monographs,  and  text-books  is  an  essential  part  of  a  medical  clinic. 
Beyond  this,  in  America  we  have  been  able  to  develop,  and  should 
aim  largely  to  increase,  the  coordination  between  the  scientific  in- 
struction of  the  student's  earlier  years  and  the  clinical  instruction 
of  his  later  years.  Cooperative  teaching  in  which  clinician  and 
pathologist,  bacteriologist,  physiologist,  or  chemist  combine  to  pre- 
sent forcibly  to  the  student  the  bearing  of  pure  laboratory  studies 


269  Columbia   University  Quarterly  [June 

upon  the  diagnosis  and  treatment  of  the  individual  patient,  and  of 
fundamental  scientific  investigation  upon  the  progress  of  clinical 
medicine,  should  be  a  definite  part  of  the  curriculum.  In  the  same 
way,  conferences  between  the  members  of  these  departments  and  the 
hospital  physicians  should  contribute  to  the  education  of  both  and 
the  increasing  efficiency  of  the  hospital.  The  education  of  the 
members  of  the  clinic's  staff  is  equally  as  important  as  the  teaching 
of  students.  There  should  be  seminars  conducted  by  the  head  of 
the  department,  conferences  on  research  work  in  which  all  members 
of  the  staft'  should  participate,  and  a  constant  attempt  in  every  way 
to  train  the  teachers  and  leaders  in  clinical  medicine  of  the  next 
generation. 

The  conditions  for  successful  scientific  investigation  are :  rea- 
sonable permanence  of  tenure,  so  that  the  best  methods  for  the 
particular  problem  in  hand  may  be  mastered;  freedom  from  the 
distractions  of  practice  and  from  overmuch  routine  teaching;  a 
good  equipment  of  the  tools  of  research ;  and  a  well-stocked  library, 
particularly  of  the  journal  literature.  Permanence  of  tenure  ob- 
tains in  all  higher  university  appointments.  Freedom  from  the 
need  to  practice  must  be  secured  by  the  provision  of  liberal  salaries 
for  the  men  who  are  to  make  academic  careers  in  clinical  medicine. 
Tools  of  investigation  comprise  laboratories  connected  with  the 
medical  clinic  and  under  the  entire  control  of  its  head,  with  all  the 
apparatus  necessary  for  the  particular  lines  of  work  which  may  be 
pursued  by  the  chief  or  any  of  his  assistants,  and  with  trained  tech- 
nical assistants  who  shall  be  to  the  director  of  the  clinic  what  proper 
bookkeepers  are  to  the  head  of  a  large  business.  The  elaborateness 
of  these  laboratories  will  depend  upon  the  resources  of  the  clinic, 
and  should  be  commensurate  with  the  productiveness  of  its  staff. 
When  problems  arise  which  require  a  degree  of  technical  skill  not 
possessed  by  any  member  of  the  clinic's  staff,  then  the  head  of  the 
proper  scientific  department  should  be  called  in  to  advise,  and  if 
desirable,  to  have  his  department  undertake  the  problem.  On  the 
other  hand,  should  work  in  physiology  or  in  bacteriology,  for  in- 
stance, already  successfully  carried  on  in  one  of  those  departments, 
require  for  its  completion  the  study  of  patients  in  the  wards,  the 
opportunity  should  be  freely  accorded  the  department  in  question. 


I9I2]  Organisation   of  Medical   Clinic  270 

The  successful  investigation  of  disease  along  certain  lines,  and 
in  particular  by  chemical  study,  cannot  be  carried  on  in  the  ordinary 
hospital  ward.  Special,  small  wards,  with  a  more  highly  trained 
staff  and  a  more  permanent  nursing  organization,  should  be  at  the 
disposal  of  the  head  of  the  clinic  for  the  conduct  of  his  research 
work,  and  that  of  his  subordinates  who  are  particularly  engaged  in 
scientific  studies.  Patients  should  be  taken  from  the  regular  ser- 
vice of  the  clinic  to  these  special  wards  and  returned  to  the  regular 
wards  after  the  study  of  their  cases  has  been  completed. 

For  the  building  up  of  an  active  school  of  clinical  investigators 
a  master  is  required,  constantly  ready  to  suggest  problems  to  the 
younger  men  and  to  aid  them  in  their  solution.  The  university 
and  the  hospital  should  be  free  to  choose  such  a  master  wherever  he 
may  be  found  and  call  him  to  the  service  of  the  clinic.  For  this,  again, 
a  salary  which  shall  make  any  but  the  most  limited  consulting  prac- 
tice unnecessary,  will  be  requisite.  The  master  in  his  turn  should 
be  free  to  accept  at  will  voluntary  assistants  in  the  research  work 
of  the  clinic,  and  there  should  be  ample  provision  made  in  this 
direction,  apart  from  the  stafif  necessary  for  the  conduct  of  the 
routine  work  of  the  hospital  and  the  teaching  institution. 

The  organization  which  will  most  perfectly  fulfill  the  conditions 
laid  down  would  be  possible  in  a  hospital  service  of  approximately 
one  hundred  and  fifty  medical  beds,  with  an  out-patient  department. 
A  smaller  number  of  beds  could  scarcely  provide  enough  material 
for  the  extensive  teaching  outlined ;  a  larger  number  would  severely 
tax  the  strength  and  administrative  ability  of  any  but  an  intellectual 
and  physical  giant — or  else  the  supervision  will  be  far  from  ideal. 
Such  a  division  should  have  three  complete  units  of  service,  each 
consisting  of  one  male  and  one  female  ward  of  approximately 
twenty-two  beds,  a  few  of  these  beds  being  in  small  rooms ;  a  clin- 
ical laboratory,  a  teaching  room  and  office  for  the  visiting  physician, 
and  the  necessary  service  rooms  of  various  kinds  for  the  wards. 
Each  such  unit  should  have  a  visiting  physician,  with  the  title  of 
assistant  professor  or  clinical  professor  in  the  university,  spending 
a  regular  part  of  his  day  in  the  hospital,  whose  duties  to  the  hos- 
pital should  be  the  ones  already  familiar  to  his  office,  and  whose 
duty  in  the  medical  school  should  be  the  instruction  of  clinical  clerks 


2/1  Cohinibia    University   Quarterly  [June 

in  the  wards.  He  should,  if  possible,  have  a  moderate  salary. 
Where  mature  residents  are  not  available,  there  should  also  be  an 
associate  visiting  physician.  He  should  have  an  assistant  in  charge 
of  the  out-patient  service  of  the  division,  who  would  be  his  substi- 
tute in  the  wards  during  absences.  This  assistant  in  turn  should 
have  an  understudy  in  the  out-patient  department.  The  assistant 
physicians  would  give  instruction  in  physical  diagnosis  in  the  dis- 
pensary and  conduct  the  recitations.  Each  unit  should  have  a 
resident  and  an  assistant  resident  ph3'sician,  serving  for  an  indefi- 
nite term.  Under  them  should  be  one  medical  interne  for  each 
ward,  appointed  for  one  year,  and  from  six  to  ten  medical  students 
serving  as  clinical  clerks. 

There  should  also  be  a  separate  service  of  about  twenty  beds  in 
small  wards  and  single  rooms,  with  a  resident  and  an  assistant  resi- 
dent physician,  chosen  especially  for  their  scientific  promise  and 
under  the  immediate  charge  of  the  director  and  the  assistant  director 
of  the  clinic.  The  subordinate  work  in  these  wards  should  be  car- 
ried on  by  voluntary  assistants  coming  to  the  clinic  to  pursue  re- 
search, and  no  student  clerks  should  be  assigned  to  them.  The 
assistant  director  should  be  chosen  from  the  younger  men  pursuing 
an  academic  clinical  career,  and  he  should  preferably  do  no  practice 
whatever.  He  should  have  the  immediate  oversight  of  the  research 
wards  and  the  research  laboratories  of  the  clinic,  and  the  oversight 
of  the  instruction  in  clinical  pathology.  He  should  give  such  of  the 
general  lectures  and  clinics  as  he  might  be  especially  equipped  for; 
he  should  take  the  place  of  the  director  during  the  absence  of  the 
latter,  and  should  have  free  entrance  to  all  the  divisions  of  the  clinic. 
He  should  hold  the  title  of  associate  professor  in  the  university. 

At  the  head  of  the  clinic  should  be  the  director,  who,  in  the  uni- 
versity, should  be  at  the  head  of  the  department  of  medicine.  He 
should  have  general  oversight  of  the  entire  ward  service,  but  imme- 
diate responsibility  only  for  such  patients  in  the  research  wards  as 
he  should  be  directly  studying.  He  should  visit  each  of  the  three 
divisions  of  the  clinic  twice  each  week,  at  a  stated  hour,  for  con- 
sultation with  the  staff  of  the  division.  He  should  draw  from  all 
divisions  of  the  clinic,  and  from  the  out-patient  department,  such 
cases  as  he  might  desire  to  present  in  his  clinical  lectures.     He 


I9I2]  Organisation   of  Medical   Clinic  272 

should  nominate  all  candidates  for  vacancies  in  any  position  in  the 
clinic.  He  should  have  the  supervision  of  all  expenditures.  He 
should  be  at  the  hospital  for  at  least  six  hours  during  each  working 
day,  and  for  at  least  nine  months  of  the  year.  Whether  he  should 
]3e  allowed  a  limited  consulting  practice  outside  of  the  hospital 
would  depend  upon  the  available  resources  of  the  university  to  com- 
pensate him  properly,  and  upon  the  provision  for  his  receiving  pri- 
vate patients  at  the  hospital.  It  would  seem  to  me  to  be  clearly  to 
the  advantage  of  the  hospital  that  he  and  the  assistant  director 
should  have  consulting  rooms  in  the  hospital,  where  patients  might 
come  to  them,  and  rooms  for  the  treatment  of  private  patients. 

The  out-patient  department  should  similarly  be  under  the  charge 
of  a  physician  in  chief,  who  should  directly  represent  the  director 
and  who  might  serve  in  the  hospital  under  the  assistant  director 
during  vacations.  He  should  have  the  direct  oversight  of  all  in- 
struction in  physical  diagnosis  and  of  expenditures. 

A  medical  clinic  such  as  has  been  outlined  could  undertake  the 
whole  instruction  in  medicine  of  from  one  hundred  to  one  hundred 
and  twenty  students.  An  analysis  of  its  organization  shows  at 
once  that  it  is  the  British  or  Scottish  teaching  hospital,  surmounted 
by  a  German  university  clinic.  Our  American  hospitals  were  the 
direct  outgrowth  of  their  British  predecessors,  but  they  had  to  be 
cramped  and  modified  to  meet  conditions  originally  provincial ;  now, 
in  our  large  cosmopolitan  cities,  they  are  rapidly  returning  to  their 
original  lines.  It  does  no  violence  to  tradition,  therefore,  to  inte- 
grate them  into  a  great  university  medical  school  and  to  add  to 
them  that  coordinating  activity  of  a  clinical  master,  which  shall 
develop  their  latent  possibilities  of  larger  educational  usefulness, 
and  permeate  them  with  that  atmosphere  of  tireless  scientific  inves- 
tigation, which  Americans  seek  in  Germany  today.  Is  it  too  much 
to  hope  that,  with  American  energy  and  open-handed  American 
generosity  at  our  disposal,  the  talent  for  organization — which  has 
been  so  marked  a  feature  of  our  contemporary  industrial  life — may 
in  the  next  generation  make  of  our  American  medical  clinics  insti- 
tutions for  the  treatment  of  the  sick,  sought  alike  by  poor  and  rich, 
and  centers  of  instruction  for  the  world? 

Theodore  C.  Janeway,  M.D. 

College  of  Physicians  and  Surgeons, 
437  West  sgth  Street,  New  York. 


COLUMBIA   UNIVERSITY   LIBRARIES 


This  book  is  due  cm  the  date  indicated  below,  or  at  the 
expiration  of  a  deflnite  period  after  the  date  of  borrowing,  as 
provided  by  the  library  rul^  or  by  special  arrangement  with 
the  Librarian  in  charge. 


DATE  BORROWED 

DATE  DUE 

DATE  BORROWED      j           DATE  DUE 

1 

! 

C28  (358^  lOOM 

Janeway 


RA981 

J25 

1912 


The  organizjjtion  of  an  American 
university  medical  clinic. 


MR  3  1  l9Sa 

CU-BEWP^-^" 

, 

BOUND 
mtuxi  t\      men 


I. 


Ilmtm 


